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1
Oxford Handbook of
Urology
Third edition
John Reynard
Consultant Urological Surgeon Nuffi eld Department of Surgical Sciences Oxford University Hospitals
Oxford, UK and
Honorary Consultant Urologist to the National Spinal Injuries Centre Stoke Mandeville Hospital Aylesbury, UK
Simon Brewster
Consultant Urological Surgeon Nuffi eld Department of Surgical Sciences Oxford University Hospitals
Oxford, UK
Suzanne Biers
Consultant Urological Surgeon Addenbrooke’s Hospital Cambridge University Hospitals Cambridge, UK
3
Great Clarendon Street, Oxford, OX2 6DP, United KingdomOxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries
© Oxford University Press, 2013
The moral rights of the author have been asserted First edition published 2005
Second edition published 2009 Third edition published 2013
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above
You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer
British Library Cataloguing in Publication Data Data available
ISBN 978–0–19–969613–0 (fl exicover: alk.paper) Printed in China by
C&C Offset Printing Co. Ltd.
Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.
v
Acknowledgements
The authors would like to express their gratitude to Dr Andrew Protheroe, medical oncologist at the Churchill Hospital, Oxford, Professor Nick Watkin, urological surgeon, and Dr Hussain Alnajjar, research fellow, both at St George’s Hospital, London, for kindly reading and commenting on parts of the manuscript. They would also like to thank Mr Padraig Malone, Mr Marcus Drake, and Mr Rowland Rees, who gave freely of their time and expertise.
vii
Detailed contents viii
Symbols and Abbreviations xix
1 General principles of management of patients 1 2 Signifi cance and preliminary investigation
of urological symptoms and signs 7
3 Urological investigations 37
4 Bladder outlet obstruction 71 5 Incontinence and female urology 127 6 Infections and infl ammatory conditions 175
7 Urological neoplasia 235
8 Miscellaneous urological disease of the kidney 395
9 Stone disease 427
10 Upper tract obstruction, loin pain, hydronephrosis 491 11 Trauma to the urinary tract and other urological
emergencies 505
12 Infertility 551
13 Sexual health 567
14 Neuropathic bladder 603
15 Urological problems in pregnancy 639
16 Paediatric urology 645
17 Urological surgery and equipment 697 18 Basic science and renal transplant 793
19 Urological eponyms 815
Index 820
Contents
Detailed contents
Symbols and Abbreviations xix
1 General principles of management of patients 1 Communication skills 2
Documentation and note keeping 4 Patient safety in surgical practice 6
2 Signifi cance and preliminary investigation of
urological symptoms and signs 7
Haematuria I: defi nition and types 8 Haematuria II: causes and investigation 10 Haemospermia 14
Lower urinary tract symptoms (LUTS) 16 Nocturia and nocturnal polyuria 18 Loin (fl ank) pain 20
Urinary incontinence 24 Genital symptoms 26
Abdominal examination in urological disease 28 Digital rectal examination (DRE) 30
Lumps in the groin 32 Lumps in the scrotum 34
3 Urological investigations 37
Assessing kidney function 38 Urine examination 40 Urine cytology 42
Prostatic-specifi c antigen (PSA) 43 Radiological imaging of the urinary tract 44
Uses of plain abdominal radiography (the ‘KUB’ X-ray—kidneys, ureters, bladder) 46
Intravenous urography (IVU) 48 Other urological contrast studies 52
Computed tomography (CT) and magnetic resonance imaging (MRI) 54
DETAILED CONTENTS ix
Radioisotope imaging 60 Urofl owmetry 62
Post-void residual urine volume measurement 66 Cystometry, pressure fl ow studies, and videocystometry 68
4 Bladder outlet obstruction 71
Regulation of prostate growth and development of benign prostatic hyperplasia (BPH) 72
Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH 73
Benign prostatic obstruction (BPO): symptoms and signs 74 Diagnostic tests in men with LUTS thought to be
due to BPH 76
The management of LUTS in men: NICE 2010 Guidelines 78 Watchful waiting for uncomplicated BPH 84
Medical management of BPH: alpha blockers 86 Medical management of BPH: 5α-reductase inhibitors 88 Medical management of BPH: combination therapy 90 Medical management of BPH: alternative drug therapy 92 Minimally invasive management of BPH: surgical
alternatives to TURP 94
Invasive surgical alternatives to TURP 96 TURP and open prostatectomy 100
Acute urinary retention: defi nition, pathophysiology, and causes 102
Acute urinary retention: initial and defi nitive management 106 Indications for and technique of urethral catheterization 108 Technique of suprapubic catheterization 110
Management of nocturia and nocturnal polyuria 116 Chronic retention 118
High-pressure chronic retention (HPCR) 120 Bladder outlet obstruction and retention in women 122 Urethral strictures and stenoses 124
5 Incontinence and female urology 127
Incontinence: classifi cation 128
Incontinence: causes and pathophysiology 130
Incontinence: evaluation 132
Stress and mixed urinary incontinence 136 Surgery for stress incontinence: injection therapy 138 Surgery for stress incontinence: retropubic suspension 140 Surgery for stress incontinence: suburethral tapes
and slings 142
Surgery for stress incontinence: artifi cial urinary sphincter 146 Overactive bladder: conservative and medical treatments 148 Overactive bladder: options for failed conventional therapy 150 Overactive bladder: intravesical botulinum toxin-A therapy 152 Post-prostatectomy incontinence 154
Vesicovaginal fi stula (VVF) 156 Incontinence in elderly patients 158
Management pathways for urinary incontinence 160 Initial management of urinary incontinence in women 161 Specialized management of urinary incontinence in women 162 Initial management of urinary incontinence in men 163 Specialized management of urinary incontinence in men 163 Management of urinary incontinence in frail older persons 164 Female urethral diverticulum (UD) 166
Pelvic organ prolapse (POP) 170
6 Infections and infl ammatory conditions 175 Urinary tract infection: defi nitions and epidemiology 176
Urinary tract infection: microbiology 178
Lower urinary tract infection: cystitis and investigation of UTI 182
Urinary tract infection: general treatment guidelines 184 Recurrent urinary tract infection 186
Upper urinary tract infection: acute pyelonephritis 190 Pyonephrosis and perinephric abscess 192
Other forms of pyelonephritis 194 Chronic pyelonephritis 196 Septicaemia 198
Fournier’s gangrene 202 Peri-urethral abscess 204
DETAILED CONTENTS xi
Epididymitis and orchitis 206
Prostatitis: classifi cation and pathophysiology 208 Bacterial prostatitis 210
Chronic pelvic pain syndrome 212 Bladder pain syndrome (BPS) 214
Urological problems from ketamine misuse 218 Genitourinary tuberculosis 220
Parasitic infections 222 HIV in urological surgery 226 Phimosis 228
Infl ammatory disorders of the penis 230
7 Urological neoplasia 235
Basic pathology and molecular biology 236 Wilms’ tumour and neuroblastoma 238 Radiological assessment of renal masses 242 Benign renal masses 244
Renal cell carcinoma: pathology, staging, and prognosis 246 Renal cell carcinoma: epidemiology and aetiology 250 Renal cell carcinoma: presentation and investigation 252 Renal cell carcinoma (localized): surgical treatment I 254 Renal cell carcinoma: surgical treatment II and non-surgical
alternatives for localized disease 256
Renal cell carcinoma: management of metastatic disease 258 Upper urinary tract transitional cell carcinoma (UUT-TCC) 260 Bladder cancer: epidemiology and aetiology 264
Bladder cancer: pathology, grading, and staging 266 Bladder cancer: clinical presentation 270
Bladder cancer: haematuria, diagnosis, and transurethral resection of bladder tumour (TURBT) 272
Bladder cancer (non-muscle invasive TCC):surgery and recurrence 276 Bladder cancer (non-muscle invasive TCC): adjuvant treatment 280 Bladder cancer (muscle-invasive): staging and surgical management
of localized (pT2/3a) disease 282
Bladder cancer (muscle-invasive): radical radiotherapy and palliative treatment 286
Bladder cancer: management of locally advanced and metastatic disease 288
Bladder cancer: urinary diversion after cystectomy 290 Prostate cancer: epidemiology and aetiology 294
Prostate cancer: incidence, prevalence, mortality, and survival 296 Prostate cancer: prevention 298
Prostate cancer: pathology of adenocarcinoma 302 Prostate cancer: grading 304
Prostate cancer: staging and imaging 306 Prostate cancer: clinical presentation 315 Prostate cancer: screening 316
Prostate cancer: prostate-specifi c antigen (PSA) 318 Prostate cancer—PSA derivatives and kinetics: free-to-total,
density, velocity, and doubling time 320 Prostate cancer: counselling before PSA testing 322 Prostate cancer: other diagnostic markers 324
Prostate cancer: transrectal ultrasonography and biopsy 326 Prostate cancer: suspicious lesions 330
Prostate cancer: general considerations before treatment (modifi ed from the 2008 UK NICE Guidance) 331 Prostate cancer: watchful waiting and active surveillance 332 Prostate cancer: radical prostatectomy and pelvic
lymphadenectomy 334
Prostate cancer—radical prostatectomy: post-operative care and complications 338
Prostate cancer: oncological outcomes of radical prostatectomy 340 Prostate cancer: radical external beam radiotherapy (EBRT) 344 Prostate cancer: brachytherapy (BT) 346
Prostate cancer (minimally invasive management of localized and radio-recurrent prostate cancer): cryotherapy,
high-intensity focused ultrasound, and photodynamic therapy 348 Prostate cancer: management of locally advanced
non-metastatic disease (T3–4 N0M0) 350
Prostate cancer: management of advanced disease—hormone therapy I 352
DETAILED CONTENTS xiii
Prostate cancer: management of advanced disease—hormone therapy II 354
Prostate cancer: management of advanced disease—hormone therapy III 356
Prostate cancer: management of advanced disease—
castrate-resistant prostate cancer (CRPC) 358 Prostate cancer: management of advanced disease—
palliative care 362 Urethral cancer 364
Penile neoplasia: benign, viral-related, and premalignant lesions 368 Penile cancer: epidemiology, risk factors, and pathology 370 Penile cancer: clinical management 374
Scrotal and paratesticular tumours 377
Testicular cancer: incidence, mortality, epidemiology, and aetiology 378
Testicular cancer: pathology and staging 380
Testicular cancer: clinical presentation, investigation, and primary treatment 384
Testicular cancer: serum markers 386
Testicular cancer: prognostic staging system for metastatic germ cell tumours (GCT) 388
Testicular cancer: management of non-seminomatous germ cell tumours (NSGCT) 390
Testicular cancer: management of seminoma, IGCN, and lymphoma 392
8 Miscellaneous urological disease of the kidney 395 Simple and complex renal cysts 396
Calyceal diverticulum 399 Medullary sponge kidney (MSK) 400 Acquired renal cystic disease (ARCD) 402
Autosomal dominant polycystic kidney disease (ADPKD) 404 Vesicoureteric refl ux in adults 408
Pelviureteric junction obstruction in adults 412 Anomalies of renal fusion and ascent: horseshoe kidney,
ectopic kidney 416
Anomalies of renal number and rotation: renal agenesis and malrotation 420
Upper urinary tract duplication 422
9 Stone disease 427
Kidney stones: epidemiology 428
Kidney stones: types and predisposing factors 432 Kidney stones: mechanisms of formation 434 Factors predisposing to specifi c stone types 436 Evaluation of the stone former 440
Kidney stones: presentation and diagnosis 442 Kidney stone treatment options: watchful waiting and
the natural history of stones 444
Stone fragmentation techniques: extracorporeal lithotripsy (ESWL) 446
Intracorporeal techniques of stone fragmentation 450 Flexible ureteroscopy and laser treatment 454 Kidney stone treatment: percutaneous nephrolithotomy
(PCNL) 456
Kidney stones: open stone surgery 462
Kidney stones: medical therapy (dissolution therapy) 464 Ureteric stones: presentation 466
Ureteric stones: diagnostic radiological imaging 468 Ureteric stones: acute management 470
Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone 472
Ureteric stone treatment 476
Treatment options for ureteric stones 478 Prevention of calcium oxalate stone formation 482 Bladder stones 486
Management of ureteric stones in pregnancy 488
10 Upper tract obstruction, loin pain, hydronephrosis 491 Hydronephrosis 492
Management of ureteric strictures (other than PUJO) 496 Pathophysiology of urinary tract obstruction 498
DETAILED CONTENTS xv
Physiology of urine fl ow from kidneys to bladder 499 Ureter innervation 500
Retroperitoneal fi brosis 502
11 Trauma to the urinary tract and other urological
emergencies 505
Initial resuscitation of the traumatized patient 506 Renal trauma: classifi cation, mechanism, grading 508 Renal trauma: clinical and radiological assessment 512 Renal trauma: treatment 516
Ureteric injuries: mechanisms and diagnosis 520 Ureteric injuries: management 522
Pelvic fractures: bladder and ureteric injuries 526 Bladder injuries 532
Posterior urethral injuries in males and urethral injuries in females 535
Anterior urethral injuries 536 Testicular injuries 540 Penile injuries 542
Torsion of the testis and testicular appendages 544 Paraphimosis 545
Malignant ureteric obstruction 546
Spinal cord and cauda equina compression 548
12 Infertility 551
Male reproductive physiology 552
Aetiology and evaluation of male infertility 554 Investigation of male infertility 556
Oligozoospermia and azoospermia 560 Varicocele 562
Treatment options for male infertility 564
13 Sexual health 567
Physiology of erection and ejaculation 568 Erectile dysfunction: evaluation 572 Erectile dysfunction: treatment 576
Peyronie’s disease 580 Priapism 584
Retrograde ejaculation 588 Premature ejaculation 590
Other disorders of ejaculation and orgasm 592 Late-onset hypogonadism (LOH) 594
Hypogonadism and male hormone replacement therapy 596 Urethritis 600
Non-specifi c urethritis and urethral syndrome 602
14 Neuropathic bladder 603
Innervation of the lower urinary tract (LUT) 604 The physiology of urine storage and micturition 608 Bladder and sphincter behaviour in the patient with
neurological disease 610
The neuropathic lower urinary tract: clinical consequences of storage and emptying problems 612
Bladder management techniques for the neuropathic patient 614 Catheters and sheaths and the neuropathic patient 622 Management of incontinence in the neuropathic patient 624 Management of recurrent urinary tract infections (UTIs)
in the neuropathic patient 628
Management of hydronephrosis in the neuropathic patient 630 Bladder dysfunction in multiple sclerosis, Parkinson’s disease, spina
bifi da, after stroke, and in other neurological disease 632 Neuromodulation in neuropathic and non-neuropathic
lower urinary tract dysfunction 636
15 Urological problems in pregnancy 639
Physiological and anatomical changes in the urinary tract 640 Urinary tract infection (UTI) 642
Hydronephrosis of pregnancy 644
16 Paediatric urology 645
Embryology: urinary tract 646 Embryology: genital tract 648 Undescended testes (UDT) 650
DETAILED CONTENTS xvii
Urinary tract infection (UTI) 654 Antenatal hydronephrosis 658 Vesicoureteric refl ux (VUR) 662 Megaureter 666
Ectopic ureter 668 Ureterocele 670
Pelviureteric junction (PUJ) obstruction 672 Posterior urethral valves (PUV) 674 Cystic kidney disease 676 Hypospadias 678
Disorders of sex development 682 Exstrophy–epispadias complex 688 Primary epispadias 690
Urinary incontinence in children 692 Nocturnal enuresis 694
17 Urological surgery and equipment 697
Preparation of the patient for urological surgery 698 Antibiotic prophylaxis in urological surgery 702 Complications of surgery in general: DVT and PE 706 Fluid balance and the management of shock in the surgical
patient 710
Patient safety in the urology theatre 712 Transurethral resection (TUR) syndrome 713 Catheters and drains in urological surgery 714 Guidewires 720
Irrigating fl uids and techniques of bladder washout 722 JJ stents 724
Lasers in urological surgery 730 Diathermy 732
Sterilization of urological equipment 736
Telescopes and light sources in urological endoscopy 738 Consent: general principles 740
Cystoscopy 742
Transurethral resection of the prostate (TURP) 744 Transurethral resection of bladder tumour (TURBT) 746
Optical urethrotomy 748 Circumcision 750
Hydrocele and epididymal cyst removal 752 Nesbit’s procedure 754
Vasectomy and vasovasostomy 756 Orchidectomy 758
Urological incisions 760 JJ stent insertion 762
Nephrectomy and nephro-ureterectomy 764 Radical prostatectomy 766
Radical cystectomy 768 Ileal conduit 772
Percutaneous nephrolithotomy (PCNL) 774 Ureteroscopes and ureteroscopy 778 Pyeloplasty 782
Laparoscopic surgery 784
Endoscopic cystolitholapaxy and (open) cystolithotomy 786 Scrotal exploration for torsion and orchidopexy 788 Electromotive drug administration (EMDA) 790
18 Basic science and renal transplant 793 Basic physiology of bladder and urethra 794
Basic renal anatomy 796
Renal physiology: glomerular fi ltration and regulation of renal blood fl ow 800
Renal physiology: regulation of water balance 802 Renal physiology: regulation of sodium and
potassium excretion 803
Renal physiology: acid–base balance 804 Renal replacement therapy 806 Renal transplant: recipient 808 Renal transplant: donor 810
Transplant surgery and complications 812
19 Urological eponyms 815
Index 820
xix
Symbols and Abbreviations
® registered trademark
> more than
< less than
equal to or greater than
equal to or less than
% percent
°C degree Celsius
d decreased
i increased
b cross-reference
7 approximately
α alpha
β beta
AAA abdominal aortic aneurysm
AAOS American Academy of Orthopaedic Surgeons AAST American Association for the Surgery of Trauma AAT androgen ablation therapy
ACCP American College of Chest Physicians ACE angiotensin-converting enzyme ACh acetylcholine
ACR albumin:creatinine ratio or acute cellular rejection ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone ADT androgen deprivation therapy
ADPKD autosomal dominant polycystic kidney disease AFP alpha-fetoprotein
AHR acute humoral rejection AI androgen-independent AID artifi cial insemination donor AIDS acquired immunodefi ciency syndrome a.m. ante meridiem (before noon) AMACR α-methylacyl CoA racemase AML angiomyolipoma
amp ampere
AMS American Medical Systems ANP atrial natriuretic peptide
a-NVH asymptomatic non-visible haematuria APD automated peritoneal dialysis APF antiproliferative factor 5AR 5α-reductase
ARCD acquired renal cystic disease 5ARI 5α-reductase inhibitor
ARPKD autosomal recessive polycystic kidney disease ART assisted reproductive techniques
AS active surveillance
ASAP atypical small acinar proliferation
ASTRO American Society of Therapeutic Radiation Oncologists ATG antithymocyte globulin
ATN acute tubular necrosis ATP adenosine triphosphate AUA American Urological Association
AUA-SI American Urological Association Symptom Index AUR acute urinary retention
AUS artifi cial urinary sphincter AVM arteriovenous malformation
BAUS British Association of Urological Surgeons BCG bacillus Calmette–Guérin
BCR bulbocavernosus refl ex
bd bis die (twice daily)
bFGF basic fi broblastic growth factor BHCG beta human chorionic gonadotrophin BLI beta-lactamase inhibitor
BMI body mass index
BMSFI Brief Male Sexual Function Inventory BNI bladder neck incision
BOO bladder outlet obstruction
BP blood pressure
BPE benign prostatic enlargement bPFS biochemical progression-free survival BPH benign prostatic hyperplasia BPLND bilateral pelvic lymphadenectomy BPO benign prostatic obstruction BPS bladder pain syndrome
BSE bovine spongiform encephalopathy BT brachytherapy
BTA bladder tumour antigen BTX-A botulinum toxin-A
SYMBOLS AND ABBREVIATIONS xxi
BUO bilateral ureteric obstruction BXO balanitis xerotica obliterans CAA Civil Aviation Authority CABG coronary artery bypass graft CAH congenital adrenal hyperplasia
CAIS complete androgen insensitivity syndrome cAMP cyclic adenosine monophosphate CAPD continuous ambulatory peritoneal dialysis CBAVD complete bilateral absence of vas deferens CCF congestive cardiac failure
CCr creatinine clearance
CD collecting duct
CEULDCT contrast-enhanced ultra-low dose computed tomography
CFU colony-forming unit
cGMP cyclic guanosine monophosphate CI confi dence interval
CIRF clinically insignifi cant residual fragment CJD Creutzfeldt–Jakob disease
CIS carcinoma in situ
CISC clean intermittent self catheterization CKD chronic kidney disease
cm centimetre CMV cytomegalovirus CNI calcineurin inhibitor CNS central nervous system CO2 carbon dioxide
COPD chronic obstructive pulmonary disease
COPUM congenital obstructive posterior urethral membrane CP chronic prostatitis
CPA cyproterone acetate
CPB chronic painful bladder (syndrome) CPPS chronic pelvic pain syndrome
CPRE complete primary repair of bladder exstrophy Cr creatinine
CRF chronic renal failure CRP C-reactive protein
CRPC castrate-resistant prostate cancer CSS cancer-specifi c survival
CT computed tomography or collecting tubule CTPA computerized tomography pulmonary angiography CTU computed tomography urography
CT-KUB CT of the kidneys, ureters, and bladder CVA cerebrovascular accident
CXR chest X-ray
Da Dalton
DCT distal convoluted tubule DE delayed ejaculation
DESD detrusor-external sphincter dyssynergia DEXA dual-energy X-ray absorptiometry (scan) DGI disseminated gonococcal infection DH detrusor hyperrefl exia
DHT dihyrotestosterone
DI diabetes insipidus
DIC disseminated intravascular coagulation dL decilitre
DMSA dimercapto-succinic acid (renogram) DMSO dimethyl sulphoxide
DNA deoxyribonucleic acid
DRE digital rectal examination
DSD detrusor sphincter dyssynergia or disorders of sex development
DVLA Drivers Vehicle Licensing Agency DVT deep vein thrombosis
EAU European Association of Urology EBRT external beam radiotherapy
EBV Epstein–Barr virus
ECF extracellular fl uid
ECG electrocardiogram ED erectile dysfunction
EDTA ethylene diamine tetra-acetic acid e.g. exempli gratia (for example) EGF epidermal growth factor eGFR estimated glomerular fi ltration rate EHL electrohydraulic lithotripsy
EIA enzyme immunoassay
ELISA enzyme-linked immunosorbant assay EMDA electromotive drug administration EMG electromyography
EMU early morning urine
EPLND extended pelvic lymphadenectomy EPN emphysematous pyelonephritis
EORTC European Organization for Research and Treatment of Cancer
SYMBOLS AND ABBREVIATIONS xxiii
EPS expressed prostatic secretions
ER extended release
ESBL extended spectrum B-lactamase ESR erythrocyte sedimentation rate
ESSIC European Society for the Study of Bladder Pain Syndrome/Interstitial Cystitis
ESWL extracorporeal shock wave therapy
etc et cetera
FBC full blood count
FGSI Fournier’s gangrene severity index FNA fi ne needle aspiration
FSH follicle stimulating hormone
ft foot/feet
FVC frequency volume chart
g gram
GA general anaesthetic GABA G-aminobutyric acid GAG glycosaminoglycan GCT germ cell tumour GFR glomerular fi ltration rate GI gastrointestinal
GIFT gamete intrafallopian transfer Gk Greek
GnRH gonadotrophin-releasing hormone GP general practitioner
GTN glyceryl trinitrate
GU gonococcal urethritis (or genitourinary) GUM genitourinary medicine
Gy gray
h hour
H+ hydrogen ion
HAL hexaminolevulinic acid
Hb haemoglobin
HCG human chorionic gonadotrophin HCO3 bicarbonate ion
HDR high-dose rate
HIFU high-intensity focused ultrasound HIF hypoxia-inducible factor HIV human immunodefi ciency virus HLA human leucocyte antigen
HMG-CoA 3-hydroxy-3-methyl-glutaryl-CoA reductase 5-HMT 5-hydroxymethyl tolterodine
HPCR high pressure chronic retention
HPF high-powered fi eld
H2O water
HO house offi cer
HoLAP holmium laser ablation of the prostate HoLEP holmium laser enucleation of the prostate HoLRP holmium laser resection of the prostate HPA Health Protection Agency
HPO42–
phosphate ion
H2PO4– phosphoric acid HPV human papilloma virus HRO high reliability organization HRP horseradish peroxidise HTLA human T lymphotropic virus Hz Hertz
IC intermittent catheterization or interstitial cystitis ICD implantable cardioverter defi brillator
i.e. id est (that is)
IFIS intraoperative fl oppy iris syndrome ISC intermittent catheterization
ICF intracellular fl uid
ICS International Continence Society ICSI intracytoplasmic sperm injection ICU intensive care unit
IDC indwelling catheter IDO idiopathic detrusor overactivity IELT intravaginal ejaculatory latency time IFN interferon
Ig immunoglobulin
IGCN intratubular germ cell neoplasia IGF insulin-like growth factor
IIEF International Index of Erectile Function
IL interleukin
ILP interstitial laser prostatectomy IM intramuscular
INR international normalized ratio IPC intermittent pneumatic calf compression IPSS International Prostate Symptom Score ISC intermittent self-catheterization ISD intrinsic sphincter defi ciency
ISF interstitial fl uid
SYMBOLS AND ABBREVIATIONS xxv
ISSM International Society for Sexual Medicine ITU intensive treatment unit
IU international unit IUI intrauterine insemination
IV intravenous
IVC inferior vena cava IVF in vitro fertilization IVP intravenous pyelography IVU intravenous urography
J Joule
JGA juxtaglomerular apparatus
K+ potassium
kcal kilocalorie kD/kDa kilodalton Kf formation product
kg kilogram
KGF keratinocyte growth factor kHz kilohertz
kJ kilojoule
kPa kilopascal
Ksp solubility product
KTP potassium titanyl phosphate (laser) KUB Kidneys, ureter and bladder (X-ray)
L litre
LA local anaesthetic LDH lactate dehydrogenase LDL low density lipid
LDR low-dose rate
LDUH low-dose unfractionated heparin LFT liver function test
LH luteinizing hormone
LHRH luteinizing hormone-releasing hormone LMWH low molecular weight heparin LNI lymph node invasion
LoH Loop of Henle
LOH late-onset hypogonadism LRP laparoscopic radical prostatectomy LSD lysergic acid diethylamide LUT lower urinary tract LUTS lower urinary tract symptom
m metre
mA milliampere μA microampere
MAB maximal androgen blockade MAG3 mercaptoacetyl-triglycyine (renogram) MAGPI meatal advancement and granuloplasty MAPP Multidisciplinary Approach to Pelvic Pain MAPS Men After Prostate Surgery (study) MAR mixed antiglobulin reaction (test) MCDK multicystic dysplastic kidney mcg microgram
MCUG micturating cystourethrography MDCTU multidetector CT urography MDP methylene diphosphonate MDRD modifi cation of diet in renal disease mEq milliequivalent
MESA microsurgical epididymal sperm aspiration MET medical expulsive therapy
mg milligram mGy milligray
MHC major histocompatibility complex MHz megahertz
MI myocardial infarction MIBG meta-iodo-benzyl-guanidine min minute
MIS Müllerian inhibiting substance MIT minimally invasive treatment mL millilitre
MMC mitomycin C
mmol millimole
MNE monosymptomatic nocturnal enuresis mo month
mOsm milliosmole MPA mycophenolate MPOA medial preoptic area MPR multiplanar reformatting
MRCoNS methicillin-resistant coagulase-negative staphylococci MRI magnetic resonance imaging
mRNA messenger ribonucleic acid
MRSA meticillin-resistant staphylococcus aureus MSMB microseminoprotein-beta
MRU magnetic resonance urography
SYMBOLS AND ABBREVIATIONS xxvii
MS multiple sclerosis
MSA multisystem atrophy
MSK medullary sponge kidney
MSU mid-stream urine
mSV milliSevert
MUCP maximal urethral closure pressure MUI mixed urinary incontinence
MUSE Medicated Urethral System for Erection MVAC methotrexate, vinblastine, adriamycin, cisplatin
Na+ sodium
NA noradrenaline
NAAT nucleic acid amplifi cation test NaCl sodium chloride
NAION non-arteritic anterior ischaemic optic nerve neuropathy NB nota bene (take note)
NBI narrow-band imaging
NDO neurogenic detrusor overactivity
NE nocturnal enuresis
ng nanogram
NGU non-gonococcal urethritis
NICE National Institute for Health and Clinical Excellence NIDDK National Institute of Diabetes and Digestive and Kidney
Diseases
NIH National Institute of Health
NIH-CPSI National Institute of Health Chronic Prostatitis Symptom Index
nm nanometre
NMNE non-monosymptomatic nocturnal enuresis nmol nanomole
NMP nuclear matrix protein NND number needed to detect NNT number needed to treat
NO nitric oxide
NP nocturnal polyuria
NSAID non-steroidal anti-infl ammatory drug NSGCT non-seminomatous germ cell tumours NSU non-specifi c urethritis
NVH non-visible haematuria od omni die (once daily) OAB overactive bladder OAT oligoasthenoteratospermia OIF onlay island fl ap
OLND obturator lymphadenectomy
OP open prostatectomy
OSA obstructive sleep apnoea Pabd intra-abdominal pressure PAOD peripheral artery occlusive disease
PaCO2 partial pressure of carbon dioxide (in arterial blood) PaO2 partial pressure of oxygen (in arterial blood) PAG periaqueductal grey matter
PAIS Partial androgen insensitivity syndrome PBS/IC painful bladder syndrome/interstitial cystitis
PC prostate cancer
PCNL percutaneous nephrolithotomy PCO2 carbon dioxide tension PCR polymerase chain reaction PCT proximal convoluted tubule
PD Parkinson’s disease
PDD photodynamic detection PDE5 phosphodiesterase type-5 Pdet detrusor pressure PDGF platelet-derived growth factor
PDT photodynamic therapy
PE premature ejaculation or pulmonary embolism PEC perivascular epithelioid cell
PEP post-exposure prophylaxis
PESA percutaneous epididymal sperm aspiration PET positron emission tomography
PFMT pelvic fl oor muscle training PFS pressure fl ow studies
PGE1 prostaglandin E1
PGF2 prostaglandin F2
PIN prostatic intraepithelial neoplasia PLAP placental alkaline phosphatase PLESS Proscar Long-term Effi cacy Safety Study PMC pontine micturition center
PMNL polymorphonuclear leukocytes PN partial nephrectomy PNE peripheral nerve evaluation
PO orally (per os)
PO2 oxygen tension
POP pelvic organ prolapse
POPQ pelvic organ prolapse quantifi cation PPS pentosan polysulphate sodium
SYMBOLS AND ABBREVIATIONS xxix
PR pulse rate
PREDICT Prospective European Doxazosin and Combination Therapy
PRP prion protein
PSA prostate specifi c antigen PTFE polytetrafl uoroethylene PTH parathyroid hormone levels PTN posterior tibial nerve PTTI parenchymal transit time index PTNS posterior tibial nerve stimulation PUJ pelviureteric junction PUJO pelviureteric junction obstruction
PUNLMP papillary urothelial neoplasm of low malignant potential PUV posterior urethral valves
PVD peripheral vascular disease Pves intravesical pressuer PVN paraventricular nucleus PVN peripheral vascular disease
PVP photoselective vaporization of the prostate PVR post-void residual
QALY quality-adjusted life year
qds quarter die sumendus (to be taken 4 times per day) Qmax maximal fl ow rate
QoL quality of life RBC red blood count RBF renal blood fl ow RCC renal cell carcinoma RCT randomized control trial RFA radiofrequency ablation RI resistive index
RNA ribonucleic acid
RP radical prostatectomy RPD renal pelvis diameter
RPF retroperitoneal fi brosis or renal plasma fl ow RPLND retroperitoneal lymph node dissection RPR rapid plasma regain
RR respiratory rate
RT radiotherapy RTA renal tubular acidosis RTK receptor tyrosine kinase
s second
SARS sacral anterior root stimulator SC subcutaneous
SCC squamous cell carcinoma SCI spinal cord injury SCr serum creatinine SEM standard error of the mean SHBG sex hormone binding globulin SHIM Sexual Health Inventory for Men SHO senior house offi cer
SIRS systemic infl ammatory response syndrome
SL sublingual
SLE systemic lupus erythematosus SNAP synaptosomal associated protein SNM sacral nerve modulation SNS sacral nerve stimulation
s-NVH symptomatic non-visible haematuria SOP standard operating procedures
SPC suprapubic catheter
SpR specialist registrar SRE skeletal-related events SSRI serotonin reuptake inhibitor ssRNA single-stranded ribonucleic acid STD sexually transmitted disease STI sexually transmitted infection SUI stress urinary incontinence
TAL thick ascending limb (of Loop of Henle) TB tuberculosis
TBW total body water
TC testicular cancer
TCC transitional cell carcinoma
tds ter die sumendus (to be taken 3 times per day) TEAP transurethral ethanol ablation of the prostate TEDs thromboembolic deterrent stockings TENS transcutaneous electrical nerve stimulation TESA testicular exploration and sperm aspiration TESE testicular exploration and sperm extraction TET tubal embryo transfer
TGF transforming growth factor
TIN testicular intratubular neoplasia (synonymous with IGCN) TIP tubularized incised plate
TNF tumour necrosis factor TNM tumour, node, metastasis
TOT transobturator tape
SYMBOLS AND ABBREVIATIONS xxxi
TOV trial of void
TPIF transverse preputial island fl ap TRUS transrectal ultrasonography
TS tuberous sclerosis
TSE testicular self-examination TUIP transurethral incision in the prostate
TULIP transuretheral ultrasound-guided laser-induced prostatectomy
TUMT transurethal microwave thermotherapy TUNA transurethal radiofrequency needle ablation TUR transurethral resection
TURBT transurethral resection of bladder tumour TURED transurethral resection of the ejaculatory ducts TURP transurethral resection of prostate
TURS transurethral resection syndrome TUU transureteroureterostomy
TUVP transurethral electrovaporization of the prostate TUVRP transurethral vaporization resection of the prostate tvl total vaginal length
TVT tension-free vaginal tape TVTO tension-free vaginal tape obturator route TWOC trial without catheter
TZ transition zone
U (international) unit UD urethral diverticulum
UDT undescended testis
U & E urea and electrolytes UI urinary incontinence
UK United Kingdom
ULDCT ultra-low dose computed tomography UPJO ureteropelvic junction obstruction USA United States (of America)
USS ultrasound scan
UTI urinary tract infection UUI urge urinary incontinence UUO unilateral ureteric obstruction
UUT-TCC upper urinary tract transitional cell carcinoma
V volt
VB3 post-prostatic massage urine vCJD variant Creutzfeldt–Jakob disease VCUG voiding cystourethrography
VEGF vascular endothelial growth factor VEGFR vascular endothelial growth factor receptor VH visible haematuria
VHL von Hippel–Lindau
VLAP visual laser ablation of the prostate VQ ventilation/perfusion (scan) VRE vancomycin-resistant enterococci
vs versus
VTE venous thromboembolism VUJ vesicoureteric junction VUJO vesicoureteric junction obstruction VUR vesicoureteric refl ux
VURD vesicoureteric refl ux with renal dysplasia VVF vesicovaginal fi stula
W watt
WBC white blood cell WCC white cell count
WHO World Health Organization wk week
WW watchful waiting
XGP xanthogranulomatous pyelonephritis
y year
YAG ytrium-aluminium-garnet (laser) ZIFT zygote intrafallopian transfer
Chapter 1 1
General principles of management of patients
Communication skills 2
Documentation and note keeping 4 Patient safety in surgical practice 6
Communication skills
Communication is the imparting of knowledge and understanding. Good communication is crucial for the surgeon in his or her daily interaction with patients. The nature of any interaction between surgeon and patient will depend very much on the context of the ‘interview’, whether you know the patient already, and on the quantity and type of information that needs to be imparted. As a general rule, the basis of good communication requires the following:
Introduction.
•
Give your name, explain who you are, greet the patient/relative appropri- ately (e.g. handshake), check you are talking to the correct person.
Establish the purpose of the interview.
• Explain the purpose of the interview from the patient’s perspective and yours and the desired outcome of the interview.
Establish the patient’s baseline knowledge and understanding.
• Use open questions, let the patient talk, and confi rm what they know.
Listen actively.
•
Make it clear to the patient that they have your undivided attention—that you are focusing on them. This involves appropriate body language (keep eye contact—don’t look out of the window!).
Pick up on and respond to cues.
• The patient/relative may offer verbal or non-verbal indications about their thoughts or feelings.
Elicit the patient’s main concern(s).
•
What you think should be the patient’s main concerns may not be. Try to fi nd out exactly what the patient is worried about.
Chunks and checks.
•
Give information in small quantities and check that this has been under- stood. A good way of doing this is to ask the patient to explain what they think you have said.
Show empathy.
• Let the patient know you understand their feelings.
Be non-judgemental
•
Don’t express your personal views or beliefs.
Alternate control of the interview between the patient and
• yourself.
Allow the patient to take the lead where appropriate.
Signpost changes in direction.
• State clearly when you move onto a new subject.
Avoid the use of jargon.
•
Use language the patient will understand, rather than medical terminology.
COMMUNICATION SKILLS
3
Body language.
• Use body language that shows the patient that you are interested in their problem and that you understand what they are going through. Respect cultural differences; in some cultures, eye contact is regarded as a sign of aggression.
Summarize and indicate the next steps.
•
Summarize what you understand to be the patient’s problem and what the next steps are going to be.
Documentation and note keeping
The Royal College of Surgeons’ guidelines state that each clinical history sheet should include the patient’s name, date of birth, and record number.
Each entry should be timed, dated, and signed, and your name and position (e.g. SHO for ‘senior house offi cer’ or SPR for ‘specialist registrar’) should be clearly written in capital letters below each entry. You should also doc- ument which other medical staff were present with you on ward rounds or when seeing a patient (e.g. ‘ward round—SPR (Mr X)/SHO/HO’).
Contemporaneous note keeping is an important part of good clini- cal practice. Medical notes document the patient’s problems, the inves- tigations they have undergone, the diagnosis, and the treatment and its outcome. The notes also provide a channel of communication between doctors and nurses on the ward and between different medical teams.
In order for this communication to be effective and safe, medical notes must be clearly written. They will also be scrutinized in cases of complaint and litigation. Failure to keep accurate, meaningful notes which are timed, dated, and signed, with your name written in capital letters below, exposes you to the potential for criticism in such cases. The standard of note keep- ing is seen as an indirect measure of the standard of care you have given your patients. Sloppy notes can be construed as evidence of sloppy care, quite apart from the fact that such notes do not allow you to provide evi- dence of your actions! Unfortunately, the defence of not having suffi cient time to write the notes is not an adequate one, and the courts will regard absence of documentation of your actions as indicating that you did not do what you said you did.
Do not write anything that might later be construed as a personal com- ment about a patient or colleague (e.g. do not comment on an individual’s character or manner). Do not make jokes in the patient’s notes. Such comments are unlikely to be helpful and may cause you embarrassment in the future when you are asked to interpret them.
Try to make the notes relevant to the situation so, e.g. in a patient with suspected bleeding, a record of blood pressure and pulse rate is important, but a record of a detailed neurological history and examination is less relevant (unless, e.g. a neurological basis for the patient’s problem is suspected).
The results of investigations should be clearly documented in the notes, preferably in red ink, with a note of the time and date when the investiga- tion was performed.
Avoid the use of abbreviations. In particular, always write LEFT or RIGHT in capital letters, rather than Lt/Rt or L/R. A handwritten L can sometimes be mistaken for an R and vice versa.
DOCUMENTATION AND NOTE KEEPING
5
Operation notes
We include the following information on operation notes:
Patient name, number, and date of birth.
• Date of operation.
• Surgeon, assistants.
•
Patient position (e.g. supine, prone, lithotomy, Lloyd–Davies).
•
Type of deep vein thrombosis (DVT) prophylaxis (AK–TEDS,
• fl owtrons, heparin, etc.).
Type, time of administration, and doses of antibiotic prophylaxis.
•
Presence of image intensifi er, if appropriate.
• Type and size of endoscopes used.
•
Your signature and your name in capitals.
•
Post-operative instructions and follow-up, if appropriate.
•
If a consultant is supervising you, but is not scrubbed, you must clearly state that the ‘consultant (named) was in attendance’.
Patient safety in surgical practice
The aviation, nuclear, and petrochemical industries are termed ‘high reli- ability organizations’ (HROs) because they have adopted a variety of core safety principles that have enabled them to achieve safety success, despite
‘operating’ in high-risk environments. Surgeons can learn much from HROs and can adopt some of these safety principles in surgical practice in order to improve safety in the non-technical aspects of care.
Foremost amongst the safety principles of HROs are:
Team working.
•
Use of standard operating procedures (SOPs):
• day-to-day tasks are
carried out according to a set of rules and in a way that is standardized across the organization.
Cross-checking:
• members of the team check that a procedure, drug, or action has been done or administered by ‘verbalizing’ that action to another team member. This is most familiar when aircraft cabin crew are asked by the pilot to check that the doors of the plane are locked shut (‘doors to cross-check’) and crew members cross to the opposite door to confi rm this has been done. In surgical practice, an example of cross-checking could be ‘antibiotic given?’, confi rmed by a specifi c reply such as ‘240mg IV gentamicin given’.
Regular audit and feedback of audit data:
• performance data (both
good and bad) are collected regularly and crucially, team members are notifi ed (e.g. in audit meetings) of where they are performing well or badly.
Establishment of variable hierarchies:
• development of a working
environment where junior staff are encouraged to ‘speak up’ if they believe an error is about to occur, without fear of criticism.
Cyclical training:
• frequent and regular training sessions to reinforce safe practice methods.
Chapter 2 7
Signifi cance and
preliminary investigation of urological symptoms and signs
Haematuria I: defi nition and types 8 Haematuria II: causes and investigation 10 Haemospermia 14
Lower urinary tract symptoms (LUTS) 16 Nocturia and nocturnal polyuria 18 Loin (fl ank) pain 20
Urinary incontinence 24 Genital symptoms 26
Abdominal examination in urological disease 28 Digital rectal examination (DRE) 30
Lumps in the groin 32 Lumps in the scrotum 34
Haematuria I: defi nition and types
The presence of blood in the urine.
The Joint Consensus Statement on the Initial Assessment of Haematuria (The Renal Association and British Association of Urological Surgeons, July 2008) now terms macroscopic or gross haematuria as ‘visible’ haematuria (VH)—the patient or doctor has seen blood in the urine or describes the urine as red or pink (or ‘cola’-coloured—occasionally seen in acute glomerulonephritis).
Microscopic or dipstick haematuria is ‘non-visible’ haematuria (NVH). Non-visible haematuria is categorized as symptomatic (s-NVH, i.e. LUTS such as frequency, urgency, urethral pain on voiding, suprapu- bic pain) or asymptomatic (a-NVH).
Non-visible haematuria (microscopic or dipstick haematuria). Blood is identifi ed by urine microscopy or by dipstick testing. Microscopic hae- maturia has been variably defi ned as 3 or more, 5 or more, or 10 or more red blood cells (RBCs) per high-power fi eld. Samples sent from the com- munity by GPs to hospital labs have a signifi cant false negative rate (due to red cell lysis in transit).
The sensitivity of urine dipstick testing of a freshly voided urine sample is now good enough for detecting haematuria that routine confi rmatory microscopy is no longer considered necessary. Dipstick haematuria is con- sidered to be signifi cant if 1+ or more. ‘Trace’ haematuria is considered negative. No distinction is made between haemolysed and non-haemo- lysed dipstick-positive urine; as long as 1+ or more of blood is detected, it is considered signifi cant haematuria.
Urine dipsticks test for haem (i.e. they test for the presence of haemo- globin and myoglobin in urine). Haem catalyses oxidation of orthotolidine by an organic peroxidase, producing a blue-coloured compound. Dipsticks are capable of detecting the presence of haemoglobin from one or two RBCs.
False-positive urine dipstick:
• occurs in the presence of myoglobinuria,
bacterial peroxidases, povidone, hypochlorite.
False-negative urine dipstick (rare):
• occurs in the presence of
reducing agents (e.g. ascorbic acid—prevents the oxidation of orthotolidine).
Is microscopic or dipstick haematuria abnormal?
A few RBCs can be found in the urine of normal people. The upper limit of normal for RBC excretion is 1 million per 24h (as seen in healthy medi- cal students). In healthy male soldiers undergoing yearly urine examination over a 12y period, 40% had microscopic haematuria on at least one occasion, and 15% on two or more occasions. Transient microscopic haematuria may occur following rigorous exercise, sexual intercourse, or from men- strual contamination.
The fact that the presence of RBCs in the urine can be a perfectly normal fi nding explains why in approximately 70% of ‘patients’ with microscopic or dipstick haematuria, no abnormality is found despite full conventional urological investigation (urine cytology, cystoscopy, renal ultrasonogra- phy, and intravenous urogram (IVU)).2 That said, a substantial proportion
HAEMATURIA I: DEFINITION AND TYPES
9
with visible and a smaller, but signifi cant, proportion with NVH will have serious underlying disease and since there is no way, other than by fur- ther investigation, of distinguishing the dipstick-positive patient without signifi cant disease from the dipstick-positive patient without signifi cant disease, the recommendation is to investigate all patients with dipstick haematuria.
What is signifi cant haematuria?
Any single episode of VH.
•
Any single episode of s-NVH (in absence of urinary tract infection
•
(UTI) or other transient causes).
Persistent a-NVH—defi ned as two out of three dipsticks positive for
•
NVH (in absence of UTI or other transient causes).
Transient (non-signifi cant haematuria) is caused by:
UTI. Treat the UTI and repeat dipstick testing to confi rm the absence
•
of haematuria. UTI is most easily excluded by a negative dipstick result for both leucocytes and nitrites. If dipstick haematuria positive with a negative dipstick result for both leucocytes and nitrites, investigate the haematuria further.
Exercise-induced haematuria or rarely myoglobinuria (VH and NVH).
• Repeat dipstick testing after a period of abstention from exercise.
Menstruation.
•
Initial investigation for s-NVH and persistent a-NVH?
Exclude UTI or other transient causes.
•
Plasma creatinine/eGFR.
• Measure proteinuria on a random sample (24h urine collections for
•
protein are rarely required).* Blood pressure (BP).
•
When is urological referral warranted?
All patients with VH.
• All patients with s-NVH.
•
a-NVH in patients aged 40y or more.
•
Persistent a-NVH (defi ned as two out of three positives for NVH).
•
For the patient <40y with a-NVH, if eGFR is >60mL/min, BP <140/90, and no proteinuria (PCR <50mg/mmol or ACR <30mg/mmol), then while the a-NVH persists, it is recommended that the patient has an annual eGFR, BP check, and proteinuria check. If VH or s-NVH develops, referral to urology for a cystoscopy and imaging is indicated. If eGFR is <60mL/min, BP >140/90, or there is proteinuria (PCR >50mg/mmol or ACR >30mg/
mmol), nephrological referral is indicated.
* Protein assessment on a single urine sample. Protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR). Signifi cant proteinuria is a PCR >50mg/mmol or an ACR >30mg/mmol.
1 British Association of Urological Surgeons (2008) Haematuria guidelines [online]. Available from: M http://www.baus.org.uk/AboutBAUS/publications/haematuria-guidelines.
2 Khadra MH (2000) A prospective analysis of 1930 patients with hematuria to evaluate current diagnostic practice. J Urol 163:524–7.
Haematuria II: causes and investigation
Urological and other causes of haematuria
Non-visible haematuria (microscopic or dipstick haematuria) is com- mon (20% of men >60y old). Bear in mind that most patients (70%—and some studies say almost 90%)1,2 with NVH have no urological pathology.
Conversely, a signifi cant proportion of patients have glomerular disease despite having normal bp, a normal serum creatinine, and in the absence of proteinuria3,4 (although it is fair to say that most do not develop progressive renal disease and those that do usually develop proteinuria and hypertension as impending signs of deteriorating renal function). The management algorithm for patients with negative urological haematuria investigations is shown on b p. 14.
Causes of haematuria Cancer:
• bladder (transitional cell carcinoma (TCC), squamous cell carcinoma (SCC)), kidney (adenocarcinoma), renal pelvis, and ureter (TCC), prostate.
Stones:
• kidney, ureteric, bladder.
Infection: bacterial, mycobacterial (tuberculosis (TB)), parasitic
•
(schistosomiasis), infective urethritis.
Infl ammation:
• cyclophosphamide cystitis, interstitial cystitis.
Trauma:
• kidney, bladder, urethra (e.g. traumatic catheterization), pelvic fracture causing urethral rupture.
Renal cystic disease
• (e.g. medullary sponge kidney).
Other urological causes:
• benign prostatic hyperplasia (BPH, the large, vascular prostate), loin pain haematuria syndrome, vascular malformations.
Nephrological causes of haematuria:
• tend to occur in children
oryoung adults and include, commonly, IgA nephropathy, post- infectious glomerulonephritis; less commonly, membrano-proliferative glomerulonephritis, Henoch–Schönlein purpura, vasculitis, Alport’s syndrome, thin basement membrane disease, Fabry’s disease, etc.
Other ‘medical’ causes of haematuria:
• include coagulation
disorders—congenital (e.g. haemophilia), anticoagulation therapy (e.g.
warfarin), sickle cell trait or disease, renal papillary necrosis, vascular disease (e.g. emboli to the kidney cause infarction and haematuria).
Nephrological causes:
• more likely in the following situations—
children andyoung adults; proteinuria; RBC casts.
What percentage of patients with haematuria have urological cancers?
Microscopic:
• about 5–10%.
Macroscopic:
• about 20–25%.5
HAEMATURIA II: CAUSES AND INVESTIGATION
11
Urological investigation of haematuria—VH, s-NVH,a-NVH aged >40y, persistent (2 out of 3 dipsticks) a-NVH Modern urological investigation involves urine culture (where, on the basis of associated ‘cystitis’ symptoms, urinary infection is suspected), urine cytology, cystoscopy, renal ultrasonography, and CT urography (CTU).
Diagnostic cystoscopy
Nowadays, this is carried out using a fl exible, fi bre optic cystoscope, unless radiological investigation demonstrates a bladder cancer, in which case one may forego the fl exible cystoscopy and proceed immediately to rigid cystoscopy and biopsy under anaesthetic (transurethral resection of bladder tumour—TURBT).
What is the role of multidetector CT urography (MDCTU) in the investigation of haematuria?
This is a rapid acquisition CT done following intravenous contrast admin- istration with high spatial resolution. Overlapping thin sections can be
‘reconstructed’ into images in multiple planes (multiplanar reformatting—
MPR) so lesions can be imaged in multiple planes. It has the advantage of a single investigation which potentially could obviate the need for the traditional ‘4-test’ approach to haematuria (IVU, renal ultrasound, fl exible cystoscopy, urine cytology), although at the cost of a higher radiation dose (a 7-fi lm IVU = 5–10mSV, 3-phase MDCTU = 20–25mSV).
There is evidence suggesting that MDCTU has reasonable sensitiv- ity and high specifi city for diagnosing bladder tumours6 (in patients with macroscopic haematuria 93% sensitivity, 99% specifi city) and that it has equivalent diagnostic accuracy to retrograde uretero-pyelography (the retrograde administration of contrast via a catheter inserted in the lower ureter to outline the ureter and renal collecting system).7 Overall, for patients with haematuria and no prior history of urological malignancy, for the detection of all urological tumours, it has approximately 65% sensitiv- ity and 98% specifi city8—so it only rarely calls a lesion a tumour when, in fact, the lesion is benign, but it still fails to diagnose a signifi cant propor- tion of urinary neoplasms (sensitivity for upper tract neoplasms 80%, for bladder tumours 60%).
The role of MDCTU (described by some as the ‘ultimate’ imaging modal- ity) in the investigation of haematuria remains controversial. MDCTU in all patients with haematuria (microscopic, macroscopic), when most will have no identifi able cause for the haematuria, has a cost (high radiation dose, fi nancial). A targeted approach, aimed at those with risk factors for urothelial malignancy (age >40y, macroscopic as opposed to micro- scopic haematuria, smoking history, occupational exposure to benzenes and aromatic amines), might be a better use of this resource, rather than using MDCTU as the fi rst imaging test for both high- and low-risk patients.
Thus, the ‘best’ imaging probably depends on the context of the patient.
Should cystoscopy be performed in patients with a-NVH?
The American Urological Association (AUA)’s Best Practice Policy on Asymptomatic Microscopic Hematuria1 (in the process of being revised at the time this 3rd edition went to press) recommends cystoscopy in all high-risk patients (high risk for development of TCC) with microscopic haematuria (the AUA still uses the term ‘microscopic’ haematuria) (see risk factors b pp. 12–13).9
Patients at high risk for TCC:
• positive smoking history, occupational
exposure to chemicals or dyes (benzenes or aromatic amines), analgesic abuse (phenacetin), history of pelvic irradiation, previous cyclophosphamide treatment.
In asymptomatic, low-risk patients <40y, it states that ‘it may be appro- priate to defer cystoscopy’, but if this is done, urine should be sent for cytology. However, the AUA also states that ‘the decision as to when to proceed with cystoscopy in low-risk patients with persistent microscopic haematuria must be made on an individual basis after a careful discussion between the patient and physician’. It is our policy to inform such patients that the likelihood of fi nding a bladder cancer is low, but nevertheless we recommend fl exible cystoscopy. The patient then makes a decision as to whether or not to proceed with cystoscopy based on their interpretation of ‘low risk’.
If no cause for haematuria (VH or NVH) is found with cystoscopy and CT urography, is further investigation necessary?
Some say yes, quoting studies that show serious disease can be identifi ed in a small number of patients where, in addition, retrograde ureterogra- phy, endoscopic examination of the ureters, and renal pelvis (ureteros- copy) and renal angiography were done. Others say no, citing the absence of development of overt urological cancer during 2–4y follow-up in patients originally presenting with microscopic or macroscopic haematuria (although without further investigations).10
For patients with negative initial investigations, the AUA’s Best Practice Policy on Asymptomatic Microscopic Hematuria9 advises repeat urinalysis, urine cytology, and BP measurement at 6, 12, 24, and 36 months, with repeat imaging and cystoscopy where dipstick or microscopic haematu- ria persists (in the process of being revised at the time of this 3rd edi- tion went to press). The diagnostic yield from repeat testing where initial tests are normal remains to be identifi ed with certainty. There is evidence that unless a patient represents with visible haematuria, repeat urologic investigation in those with persistent dipstick or microscopic haematuria will not identify any additional signifi cant urologic pathology and neph- rological investigation only in a very small number of patients with IgA nephropathy.11
The EAU currently has no policy for the management or follow-up of patients with persistent dipstick or microscopic haematuria.
